Scribe America OP Final Exam Questions & Answers Verified 100%

scribes can - ANSWERdocument the SOAP scribes cannot - ANSWERpartake in any activity that may affect patient health or outcome; touch patients; handle bodily fluids or specimens; sign or authenticate any chart or record; give verbal orders or submit electronic orders new patient - ANSWERno previous records; longer visit; detailed chart established patient - ANSWERprevious records available; shorter visit; concise chart diagnostic clinic visit - ANSWERnew problem; cc: new symptom; goal is to determine the cause of the problem and appropriate treatment health maintenance clinic visits - ANSWERcheck-up; cc: management of {insert chronic problem}; goal is to assess progress of on-going/chronic medical problems clinic flow - ANSWERcheck-in, physician evaluation, orders & results, assessment & plan, check-out meaningful use includes - ANSWERcc; vital signs: HR, BP, T, RR; height, weight, BMI; smoking status nurse/MA assessment - ANSWERconfirm chief complaint; review allergies/medications' brief past medical history history and physical (H&P) includes - ANSWERHPI, ROS, PE orders include - ANSWERlaboratory studies, imaging studies, procedures results include - ANSWERmay result during visit (rare) or in a few days assessment - ANSWERthe list of diagnoses plan - ANSWERfollow-up with specialist if necessary; instructions for lifestyle and preventative care; follow-up for next routine appointment check-out - ANSWERhome vs sent to the ED; patient education provided; patient will often stop at the front desk on the way out to schedule next appointment social history includes - ANSWERtobacco use; alcohol use; illicit drug use; occupation; living circumstances smoking status - ANSWERcurrent, former, never, second-hand exposure alcohol use status - ANSWERnever, occasionally'socially, daily, chronic alcoholic occupation status - ANSWERemployed, unemployed, on disability living circumstances status - ANSWERlives alone; with family/friends; nursing home'assisted living; hospice; homeless/shelter pediatric SHx - ANSWERcaretaker (mother,father, grandparent); attends daycare; attends school; has brothers/sisters; second-hand smoke exposure; immunizations up to date HTN risk factors - ANSWERFHx of HTN, obesity, DM, high sodium diet, smoking, EYOH HTN CC - ANSWERoften asymptomatic, hypertension, headache, chest pain, palpitations, blurred vision, epistaxis